final report on the accident to jodel dr1050 registered oo

Air Accident Investigation Unit
(Belgium)
CCN
Rue du Progrès 80 Bte 5
1030 Brussels
FINAL REPORT ON THE ACCIDENT
TO JODEL DR1050 REGISTERED
OO-MOU ON KIEWIT AIRFIELD
ON 16 AUGUST 2009
Ref. AAIU-2009-14
Issue date: 15 January 2010
Status: Final
AAIU-2009-14/ Final/ OO-MOU
AAIU-2009-14/ Final/ OO-MOU
Table of Content.
Foreword
2
Synopsis
3
1.
Factual information
1.1.
Chronology of the events
1.2.
Injuries to persons
1.3.
Damage to aircraft
1.4.
Other damage
1.5.
Personnel information
1.6.
Aircraft information
1.7.
Meteorological information
1.8.
Aids to Navigation
1.9.
Communication
1.10. Airport information
1.11. Flight Recorders
1.12. Wreckage and Impact information
1.13. Medical and Pathological information
1.14. Fire
1.15. Survival Aspects
1.16. Test and Research
4
4
6
6
7
7
8
13
13
13
14
15
15
16
16
16
16
2.
Analysis
17
3.
4.
Conclusions
Safety recommendations.
18
18
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FOREWORD
This report is a technical document that reflects the views of the investigation team on
the circumstances that led to the accident,
In accordance with Annex 13 of the Convention on International Civil Aviation, it is not
the purpose of aircraft accident investigation to apportion blame or liability. The sole
objective of the investigation and the Final Report is the determination of the causes,
and define recommendations in order to prevent future accidents and incidents.
In particular, Article 13 of the King’s Decree of 9 December 1998 stipulates that the
safety recommendations made in this report do not constitute any suspicion of guilt or
responsibility in the accident.
Unless otherwise indicated, recommendations in this report are addressed to the
Regulatory Authorities of the State having responsibility for the matters with which the
recommendation is concerned. It is for those Authorities to decide what action is taken.
The investigation was conducted by L. Blendeman.
NOTE:
For the purpose of this report, time will be indicated in UTC, unless otherwise
specified.
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Synopsis
Date and hour of the accident
Sunday 16 August 2009 at 09:45 UTC.
Aircraft
Type: JODEL DR 1050 Ambassadeur
Registration: OO-MOU
Accident Location:
On Kiewit Airfield, EBZH
Aircraft Owner
Privately owned by the pilot
Type of flight
Private
Persons on board
1, slightly injured
Abstract.
The aircraft is based in EBZH, Belgium. The pilot-owner of the airplane decided to fly to
EBDT, and participate to the fly-in organised by the Diest Aero-club.
The airplane took off at 08.29 UTC.
The airplane came back from EBDT at 09: 40 UTC; as per procedure, he crossed the
airfield to reach the circuit, and land.
There was a second airplane in the circuit, that took off at 09:03UTC to perform a series
of touch-and-go.
Realizing the second airplane, lower and to its left, was landing, the airplane broke the
approach, and went for a go-around.
When the pilot wanted to increase the power, the engine coughed, and stopped.
The airplane was at that time at the RH side of the airfield. The pilot turned the aircraft to
the left in order to come back over the airfield. At that time (probably when turning to the
right again), the airplane stalled, and went down, nose first in a corn field next to the
landing strip.
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1. Factual Information
1.1. Chronology of the events
The aircraft was based in EBZH, Belgium. The pilot-owner of the airplane
decided to fly to EBDT, and participate to the fly-in organised by the Diest
Aero-club.
The airplane took off at 08.29 UTC.
The airplane came back from EBDT at 09: 40 UTC; as per procedure, he
crossed the airfield to reach the circuit, and land.
There was a second airplane in the circuit, that took off at 09:03UTC to perform
a series of touch-and-go. The presence of this airplane was not noticed by the
pilot of OO-MOU, when reaching the circuit of EBZH.
The pilot of OO-MOU noticed the presence of the second airplane when turning
on final. The second airplane was in front of him (200m) and lower. The pilot of
OO-MOU decide to abort the approach, turned the airplane to the right, to fly
parallel to the runway.
When the pilot wanted to increase the power, the engine coughed, and
stopped.
The airplane was at that time flying parallel to the landing strip, on the RH side.
The pilot turned the aircraft to the left in order to come back over the airfield. At
that time, the airplane stalled, and went down, nose first in a corn field next to
the landing strip.
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1.2. Injuries to persons
Injuries
Fatal
Serious
Minor
None
Total
Pilot
0
0
1
0
1
Passenger
0
0
0
0
0
Others
0
0
0
0
0
Total
0
0
1
0
1
1.3. Damage to aircraft
The airplane is heavily damaged.
The wooden structure of the LH wing is broken, having suffered the initial
impact.
The tail structure is shattered.
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1.4. Other damage
None.
1.5. Personnel information
Pilot.
Sex:
Age:
Nationality:
Licence:
Rating:
Medical:
male
74 years old
Belgian
Private Pilot Licence first issued on 20 September 1973, valid until
9 July 2013.
Single Engine Piston (Land), valid until 30 April 2010.
Class II, valid until November 2009.
Proficiency check performed on 26/4/2008 on AA-5A registered OO-RTK.
The pilot had an extensive flight time experience on Single Engine Piston. He
flew a total of 3310:68 FH, from which 1468:52 FH on the OO-MOU.
The last 5 years, he flew an average of 44 FH per year, from which an average
of 16 FH on the OO-MOU.
In 2009, he flew the OO-MOU for 3:12 FH in July and August.
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1.6. Aircraft information
The Jodel DR-1050 is a single engine, low wing three /four seater. It is
equipped with a classic landing gear.
The construction is made out of wood and canvas.
This type of airplane was manufactured between 1959 and 1965.
The Type Certificate data sheet N°34 covers the DR100 A model and variants,
including the DR 1050 A.
The aircraft type is listed by EASA as an “Annex II Type” aircraft, for which the
Basic European Regulation EC1592/2002 does not apply. Note 7 of page 1 of
the said document states further:
Certain aircraft (some Jodel series, Emeraude series, including Smargd and Linnet) have
been declared as Annex II because of direct similarity with the original Jodel D11 and
CP30 aircraft, even though design/production of later variants may not fit in
with the 1955/1975 criterion. Similarly, the Beagle Airedale has also been accepted as
Annex II as a direct development of the Auster series which are clearly Annex II.
As a consequence, the airplane is not eligible for the issue of a European
Airworthiness Certificate, but gets rather a Permit to fly (Laisser-passer de
navigation – Luchtvaartpas) for compliance to the Belgian National
Airworthiness Requirements.
Airframe
Manufacturer: Société Aéronautique Normande – Aérodrome de Bernay.
Type: DR 1050 Ambassadeur
Serial Number: 399
Built year: 1963
Registration: OO-MOU
Certificate of Registration: Nr 2321, issued on 15 February 1978.
Certificate of Airworthiness: Laisser-passer de navigation – Luchtvaartpas
issued on 16 July 2009, valid until 14 July 2010.
Total Flight Hours: 2678 h 11’
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Engine
Manufacturer: Rolls Royce
Type: O-200-A
Serial: 25R567
Total Flight Hours: 1511:33 FH
Propeller
Manufacturer: Hoffmann
Type: HO14-170 S123
Serial: 22174
Total Flight Hours: 1485:31 FH
Maintenance
The maintenance was performed by the pilot-owner, as authorized by the
Belgian CAA on 12 March 1999. The authorization is limited to the following:
performance of scheduled maintenance, in accordance with the
manufacturer’s requirements.
embodiment of airworthiness directives, as required by the Belgian CAA.
to perform simple repairs and modifications on the airframe, engine and
accessories.
to perform the annual check for the renewal of the Permit to fly /
Luchtvaartpas – Laisser passer de navigation.
The maintenance was performed in accordance with the Belgian CAA
requirements. The last annual inspection was performed on 5 July 2009.
During the inspection, the engine and the fuel system was checked, in
particular;
Fuel gauges,
Fuel selector switch
Fuel cut-off switch
The electrical fuel pump was not functioning, which was corrected by replacing
the circuit breaker. The fuel pump was functioning.
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The Fuel system
The airplane is equipped with two fuel tanks;
one forward, behind the instrument board,
the other aft, under the passenger seat.
The Flight Manual (Edition 1 – December 1965) found in the airplane
documentation, and the markings in the airplane indicates the following
capacity;
-
Forward Tank: 52 liters
Aft Tank: 54 liters
The Type Certificate data sheet N° 34 (Edition 8 – January 1968) states that
both tanks have a capacity of 55 liters, The aft tank has a useable capacity of
only 51 liters, the last 4 liters are only useable in cruise flight.
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Use of the fuel tanks: Procedure.
The Type Certificate data sheet N° 34 (Edition 8 – January 1968) defines the
following procedure:
Take-off and landing using the Forward Fuel Tank.
Should the rear seat be unused (either by a passenger or cargo), use the
Forward Fuel Tank first.
If the load on the rear seat exceeds 70 kg; use the Rear Fuel Tank first.
For the intermediate cases, use both fuel tanks alternatively at the fourth
of their capacity, start with the Forward Fuel Tank for a forward centering,
and with the Rear Fuel Tank in case of a rear centering.
The Flight Manual (Edition 1 – December 1965) found in the airplane
documentation, indicates the following procedure (extracts pertaining only to
the fuel system):
Before Take-off:
E–
Fuel: Forward Fuel Tank selected,
(warning lights extinguished);
fuel pump on.
Climb:
Switch off the electrical pump.
WARNING: the five last liters of the aft tank are not useable in
climb.
Cruise:
Use of the fuel tanks.
Avoid an important difference between the 2 fuel tank quantity
indicators. The various loading possibilities have an important
impact on the balance of the airplane.

For forward centered airplane, use the forward tank first,

For aft centered airplane, use the aft tank first.
For intermediate cases, use the tanks alternatively by steps of ¼
of their capacity.
Descend

Electrical pump on, and Forward tank selected.
The pilot stated that, in a general way, he was using the Forward tank for takeoff and landing, and switched to the aft tank in cruise. He was further using the
aft tank until empty. This would give him the certainty of maintaining a
maximum quantity of fuel in the forward tank.
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Fuel Consumption.
The flight manual gives the following figures of fuel consumption for
a weight of 750 kg
Puissance % CV
75% - 76 CV
65 % - 66 CV
Consommation (l/h)
21.3
18.5
Autonomy
5.1
6
The owner states he experienced an average consumption of 16-17 l/h.
Owner
The owner of the airplane is the pilot.
1.7. Meteorological information
Observed at EBZH Airfield
Wind:
Direction: 270°
Speed: 04 knots
Visibility: more than 6000 m
Clouds: 1000 ft
Pressure: 1016 mb
Temperature: 18°C
1.8. Aids to Navigation
Not applicable
1.9. Communication
Kiewit airfield can be reached at the following:
Call sign : Hasselt Radio 118.325 MHz (Info only - no ATC)
Prior Permission Required (PPR) :
00 32 (0)11 21 25 50 * 00 32 (0)475 35 36 47.
OO-MOU is equipped with a radio.
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Several witnesses heard a short message ‘Kiewit Ground’ on the radio seconds
before the crash.
1.10.
Airport information
Kiewit airfield, called the ‘oldest airfield in Belgium’, is located 8km N of the
city of Hasselt, Limburg. The airfield is operated by day time only.
Address:
Aeroclub Kiewit
Luchtvaartstraat, 100 Bus 1
B - 3500 Hasselt
Coordinates: 50°58'12"N - 005°22'30"E
Elevation: 43m
Runway QFU: 090° / 270°
Runway dimensions: 600m x 18m
Surface : grass.
Runway strength : 5700kg
Procedures: RWY 27: right-hand circuit Circuit ALT 1 400 ft
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1.11.
Flight Recorders
Not applicable
1.12.
Wreckage and Impact information
The airplane fell down in a stall. The left wing hit the ground first, and the
airplane crashed, inverted, with the fuselage into an irrigation ditch.
This protected the cabin to be further crushed by the airplane hitting the
ground.
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1.13.
Medical and Pathological information
Not applicable.
1.14.
Fire
There was no fire
1.15.
Survival Aspects
Not Applicable
1.16.
Test and Research
Propeller
One blade of the 2-blades wooden propeller was broken, while the other was
intact.
Fuel System.
The remaining fuel was drained from the fuel tanks.
The Forward tank was empty.
The aft tank contained 20 liters of fuel.
The fuel tank selector switch was in the “FWD Tank” position.
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2. Analysis.
2.1.
Engine operation.
The findings on the propeller were consistent with the pilot’s statement and
witnesses report that the engine stopped in flight. The engine was not
delivering power at impact.
2.2.
Fuel Planning.
The pilot states he filled up the fuel tanks in July 2009 in EBAW.
The flight log shows the following:
Date
Flight
04/07/2009
25/07/2009
28/07/2009
28/07/2009
07/08/2009
16/08/2009
16/08/2009
Engine run
EBAW - EBZH
EBZH - EBZW
EBZW - EBZH
Local EBZH
EBZH – EBDT
EBDT - EBZH
Flight time
43 min
30 min
15 min
40 min
Counter
2070.30
2070.42
2071.25
2071.55
2072.10
2072.40
2074.24
This means an operating time of 3:42 hours, on which we can add the
equivalent of 1 hour for the remaining 20 liters of fuel recovered from the aft
tank. This means an operating time quite close to the theoretical autonomy of 5
hours indicated in the flight manual.
The difference would come from fuel leaking from the wreckage for an
unknown volume, as witnessed during lifting of the wreckage.
2.3.
Fuel Management.
The pilot stated that he recalled not having rigorously applied the fuel tank
selection procedure during previous flights, and the last flights were mainly done
on the forward tank.
The procedure is designed in order to use the aft tank mainly in cruise, so that it
empties first, and the switching to the forward tank, (even in the case it runs dry)
would happen in cruise, i.e. with sufficient height. This would ensure that the
forward tank remains with the most fuel, allowing the landing on the forward tank,
located above the carburetor level (positive pressure) to minimize the risk of fuel
starvation.
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3.
Conclusions.
3.1.
3.2.
Findings
-
The pilot had a valid Pilot’s licence and medical certificate.
-
The pilot had extensive flight experience on this airplane.
-
The aircraft had a valid permit to fly.
-
The airplane was maintained in accordance with the manufacturer’s
maintenance program.
-
There were 20 liters of fuel remaining in the aft tank, while the forward
tank was found empty.
-
The engine was not delivering power at impact.
Causes.
The cause of the accident is fuel starvation, causing the engine to stop,
when the airplane was maneuvering at low speed and low altitude,
resulting in a stall.
4.
Safety recommendations.
To BCAA / training school
This accident is a perfect illustration of the importance of following procedures,
even for very experienced pilot having an extensive knowledge of the airplane.
We suggest training schools to use the content of this report in human factors
courses.
15 January 2010
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